Childbirth is implicated in increasing a woman's lifetime risk of experiencing adverse pelvic floor changes associated with incontinence, negatively impacting her quality of life. Management of 2nd stage labor is a modifiable factor related to pelvic floor health. How a woman pushes during 2nd stage, either spontaneously or directed, may affect this risk. Findings from the randomized clinical trial PERL: Urinary Incontinence Prevention: Reducing Birthing Risk (R01-NR4007) suggests spontaneous pushing method does not significantly decrease urinary leakage post partum. However, review of a subset of participants (N=58) using audiotapes from their 2nd stage labor indicate fidelity to group assignment (spontaneous or directed) was not consistently maintained due to provider and participant reasons. In this subset, analysis of audiotapes assessing actual pushing method trends towards significance indicating benefit of spontaneous pushing to reduce post partum leakage (p= 0.048) but is under powered. The need to reduce incontinence risk in childbearing women demands we expand the scientific evidence available regarding 2nd stage and prevention of adverse pelvic floor changes. Therefore a secondary analysis of 162 audiotapes representing 17,929 minutes of 2nd stage labor will be done using qualitative and quantitative methods to determine actual pushing compared to randomized assignment and associated provider communication. Using segments of audio taped labor interaction, focus groups targeting 30 bedside maternity care providers will be completed investigating clinical considerations in implementing 2nd stage strategies. The AIMS of this project are to: Aim 1: Investigate the relationship between actual pushing method used during 2nd stage labor and risk for incontinence post partum. H1: We hypothesize there will be a significant cross over effect that occurs between original assignment through randomization and actual pushing effort during 2nd stage labor and H2. Using actual pushing type for group assignment compared to random group assignment, severity of urine leakage at 12 months post partum will be significantly less in the spontaneous compared to directed group. AIM 2: Investigate maternity care providers'rationale and description of clinical indicators that influence how they manage 2nd stage labor and document how provider verbal instruction may change in response to maternal pushing efforts over the course of 2nd stage labor. H3: We hypothesize that pushing method (directed or spontaneous) encouraged by maternity care providers is dynamic;influenced by time, visibility of the vertex and response of the laboring woman. This investigation will be the foundation for a prospective trial testing provider use of evidence based 2nd stage management strategies and prevention of adverse pelvic floor changes. Reducing incontinence in even 5% of the almost 3 million women who give birth annually removes this burden in over 140,000 women annually. PUBLIC HEALTH RELEVANCE: Childbirth have been implicated as increasing a woman's lifetime risk of experiencing pelvic floor changes, including incontinence, that negatively impact a woman's quality of life. The second stage of labor resulting in vaginal birth is the most important modifiable factor related to pelvic floor changes and how a woman pushes during this phase, either spontaneously or as directed by a health care provider is hypothesized to affect this risk. Our goal in this project is to determine the linkage between how a woman pushes and her risk of incontinence so that we can aid health care providers in the prevention of incontinence associated with childbirth representing a wise public health investment in prevention of a critical women's health condition.